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Saturday, March 4, 2017

What is the usefulness of best practice medicine?

I would like to define "Best Practice Medicine" and then analyze it's usefulness as far as it pertains to the respiratory therapy community. My "theory" is that it is not used properly.

Best Practice. According to The University of Iowa College of Nursing, it means: "The use of care concepts, interventions and techniques that are grounded in research and known to promote higher quality of care and living for... people."

Best Practice Medicine. It is using the "best practices" available based on the medical research, particularly respiratory therapy research. and in real life practice.

Now, let's examine another term:

Evidence Based Medicine. According to Sackett, et al, 1996, it "is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research."

So you have researchers performing studies. They come to conclusions based on a preponderance of the evidence. They come to conclusions. They are just humans, so their analysis and conclusions may be accurate. However, they may also be flawed. This brings me to two more definitions.

Scientific data. It's what is considered as fact. It's what is. Science shows that beta 2 adrenergic medicine like albuterol relaxes smooth muscles and opens airways in individuals suffering from asthma attacks. This is proven. This is fact. This cannot be debated. Trees are green. This is fact. Science has shown that albuterol does not treat inflammation, and therefore has no use in treating pneumonia. It also has no use in treating bronchiolitis, that suction of the airway is all that is needed. Science has shown that wheezing caused by airways narrowed due to increased intrathoracic pressure due to heart failure and pulmonary edema will not resolve by using albuterol, that it requires other medicines.

Theory. This is what is assumed. It is not a fact. It is what isn't or what is: we do not know. It is not up to a consensus (see below). So, a theory may be that bronchodilators benefit all that wheezes. A theory may be that albuterol will benefit heart failure, that it will benefit bronchiolitis, that it will benefit all respiratory diseases that produce annoying lung sounds.

Consensus. It is what a majority of people believe. It is often mistaken for science. It is often mistaken for fact. For example, you often hear in the news that a consensus of scientists, or 99% of them, believe in global warming. So you have people in the media using this data to claim that global warming is a fact. A consensus of doctors believe all that wheezes benefits from albuterol. A consensus of doctors is that albuterol will resolve wheezing and dyspnea caused by pneumonia, pneumothorax, pleural efffusions, heart failure, and dehydration. However, a consensus does not prove science. In science, it either is or is not. There is no in between. Trees are either green or they are not green. Bronchodilators either open airways or they do not. A consensus does not change this. Unfortunately, a consensus is usually all that is needed to make people think something that is not actually is.

Analytical data. It's what is shown. It's what happens in the clinical setting. Albuterol breathing treatments are given to many asthmatics. Asthmatics feel better after the treatment. Albuterol breathing treatments are given to heart failure patients because they produce that annoying upper airway audible wheeze as secretions sit on the vocal cords and these patients are short of breath. The treatments have no effect. In fact, as they enter more fluid into the airway, they often make that audible wheeze louder. They are given to kids with bronchiolitis. These treatments have no effect. They are given to pink puffers. These treatments have no effect. This is what happens in the clinical setting. This is what is observed before, during, and immediately after a therapy is given.

Conclusion. This is what the researchers assume based on the scientific data and the analytical data. However, conclusions are often flawed based on the bias, ignorance, or lack of clinical practice by the researchers involved. This is not a knock on researchers, it's just a fact. It can then be assumed that albuterol is useful for asthma based on the scientific data and analytical data. However, it is often assumed that albuterol is useful for all these other lung ailments, even though the scientific data and analytical data do not match. This is because there is a third element that comes into play here.

It sounds good, it makes me feel good, so it must be true. You have a patient come in with trouble breathing. You have no idea the cause. You have no idea if it's caused by bronchospasm. So, even though there are many other potential causes, you order the respiratory therapist to give beta adrenergic breathing treatments. You have no idea of the usefulness of doing this. But, if makes you feel like you are doing something. So, my argument is that this is what constitutes as best practice medicine.

Cook book medicine. You do not know what medicines will work for what patients until you obtain your definitive diagnosis. So, what you do is you throw everything you have at this patient that is considered safe. Any patient who comes into the hospital who is short of breath is treated as though they have asthma. It's the same as primitive medicine, and is often described as "all that wheezes is treated as asthma."

Protocols. This is where you assess the patient, determine a score based on an algorithm, and treat the patient based on the score. I will give two extremes here in my example. For instance, a zero means your patient has clear lung sounds, no wheezes, no paradoxical breathing, and is not short of breath. A 10 means the patient is in severe respiratory distress. A zero means you do not give a breathing treatment. A 10 means you give a continuous breathing treatment with albuterol. The experts say this protocol is based on best practice medicine. However, those who do the treatments, i.e. the respiratory therapists, think it is a waste of time in most instances. When you ask them why, they say, "Because, how do you know, that just because a person scores a 10, that they are having bronchospasm? How do you know the albuterol breathing treatments will do any good?" You don't. And this proves my point, that the medical profession is not based on best practice medicine, or evidence based medicine, it is based on "it sounds good, it makes me feel good, so it must be true."

Okay so the researcher says, "If the bronchodilator is not working, then more are needed to open the airways." To this I say, "there are other medicines that will treat the underlying problem." So you will have researchers say, "Well, the patient says she feels better after the treatment." To this you say, "This is called the placebo effect of albuterol."

References:

"Csomay Center - Best Practices for Healthcare Professionals," University of Iowa College of Nursing, https://nursing.uiowa.edu/hartford/best-practices-for-healthcare-professionals, accessed 3/4/17

Sackett, David L., et al., "Evidence based medicine: what is it and what is it not?" British Medical Journal, 1996, http://www.bmj.com/content/312/7023/71, accessed 3/4/17

Perleth, M., "What is 'best practice' in health care? State of the art and perspectives in improving the effectiveness and efficiency of the European health care systems," 2001 Jun;56(3):235-50, https://www.ncbi.nlm.nih.gov/pubmed/11399348, accessed 3/4/17